Hemoptysis is a serious medical problem requiring urgent or emergency management. This presentation discuss this in a lucid way

1. MANAGEMENT OF HEMOPTYSIS
Dr R.S Dhaliwal
MBBS,MS,DNB(Surg),M.Ch,DNB(CTV Surg)
FACS,FCCP,FNCCP,FICA,FIACS
Prof & HOD , Cardiovascular & Thoracic Surgery,
P.G.I.M.E.R, Chandigarh,India

2. INTRODUCTION
• Hemoptysis - Expectoration of blood
originating from the tracheobronchial tree or
pulmonary parenchyma
• Massive Hemoptysis – Expectoration Of >600
ml blood in 24 hrs
• Very important symptom which brings the patient
to the doctor quickly
• Can occur directly or indirectally due to any
chest disease

3. Etiology
• Pulmonary tuberculosis – active or its late sequallae
• Bronchiectasis
• Bronchial carcinoma
• Lung abcess
• Aspergilloma
• Pulmonary infarct
• Necrotizing Pneumonia
• Chest trauma –airways injury
• Pulmonary AV malformation and telangiectasis
• Iatrogenic –PA catheter Bronchoscopic biopsy
• Cardiac Disorders –MS, Eisenmenger, Cyanotic CHD
• Diffuse parenchymal disease-SLE,Wegner’s granuloma
• Idiopathic

4. Investigations
• Sputum Cytology
• X-Ray Chest
• CT Scan
• Bronchoscopy
• Angiography
• Tuberculin test or ELISA tests

5. Management
Objects of Management -
Prevent asphyxiation
Localize site of bleeding
Arrest the bleeding
Determine cause of hemoptysis
Treat the patient definitively

6. Medical Management
• Head low with bleeding side dependent
• Sedation- Non narcotics
• Volume Replacement - IV fluids
-Blood transfusion
• Clear airways of blood and secretions
• Cough Suppressants
• ATT- Use in active T.B. with hemoptysis
-broad spectrum antibiotics

7. Methods to control hemoptysis
• Endobronchial Measures
Ice cold saline Lavage
Ballon Tamponade
Pulmonary Isolation
• Arterial Embolization
• Mechanical Ventilation with PEEP
• Vasoactive Drugs
• Radiotherapy
• Intracavitary Treatment

8. Surgical Therapy
• Surgical rather than medical methods reduce
mortality.Lung resections is most effective
method to control massive hemoptysis and
prevent recurrance of hemoptysis
• Higher mortality in emergency surgery
• Ongoing bleeding at time of surgery – most imp.
factor for mortality.
• Spillage of blood,pus and infected secretions in
dependent normal lung–main cause of problems
• Poor PFT –Very imp. cause of mortality &
morbidity

9. Criteria for Surgical Therapy
• Localized site of bleeding
• Adequate pulmonary functions
• No medical contrindications
• Resectable Br. carcinoma without distant
metastases
• No mitral valve disease ( requiring cardiac
surgery)

10. Indications for Urgent surgery
• Fungus ball (almost all cases will rebleed after
any control method)
• Lung abcess ( erosion of a large vessel)
• Failure of control methods
• Cavity - with a movable mass, emptying and
quick refilling, persistent radiodensity
• Obstruction of the main or lobar bronchus due to a clot -
can not be removed during rigid bronchoscopy
• Endobronchial methods and arterial embolization can
control hemoptysis In majority of patients temporarily

11. Surgical Techniques
• Pulmonary Resections - Segmentectomy
Lobectomy, or Pneumonectomy
• Physiological Lung Exclusion
• Collapse Therapy - Thoracoplasty or plombage
• Cavernostomy and packing
• Bronchial arteries ligation & ligation of chest
wall collateral vessels
• Anesthesia-Isolation of bleeding lung essential
Single lung ventilation with Double lumen tubes
Standard endotracheal tube in normal bronchus
Endobronchial blocking catheters or gauze
packing of bleeding bronchus also tried.

12. Pulmonary Resections
• Standard treatment for massive / recurrent
hemoptysis of any etiology.Removal of
bleeding diseased lobe or lung is ideal.
Postolateral thoracotmy is usual incision.
Vascular adhesions present between lung
and chest wall in T.B &infective diseases –
makes it time consuming,more blood loss
and difficult . May need pleuro pneumon-ectomy
with higher mortality and
complications like BPF, Empyema and
space problems

13. Physiological Lung Exclusion
• Life saving Alternative/Adjunct to a difficult or
hazardous lung resection due to dense vascular
adhesions,fibrosis and calcification between chest
wall and lung
• PHYSIOLOGICAL BASIS
INVOLVED PART OF LUNG ISOLATED BY DIVISION OF
* PULMONARY ARTERY
* BRONCHUS & BRONCHIAL ARTERIES
* VIABILITY OF ISOLATED LUNG MAINTAINED
BY
* VASCULAR ADHESIONS WITH CHEST WALL
* INTACT PULMONARY VEINS FOR DRAINAGE

14. SURGICAL TECHNIQUE
• ANTERO LATERAL THORACOTOMY
• J STERNOTOMY
• MINIMUM LUNG MOBILISATION- NEAR
HILUM
• PULMONARY ARTERY LIGATION DONE
EXTRA OR INTRAPERICARDIALLY
* INVOLVED BRONCHUS DIVIDED AND
CLOSED
* PULMONARY VEINS PRESERVED

17. RESULTS
• Hospital mortality Nil
• Post Operative Empyema Nil
• Residual Space Nil
• Recurrance of Hemoptysis 1
(FOB - other side Bleeding )
• Follow up up to 18 yrs
No Problem
No BPF or Empyema

18. CONCLUSIONS
PHYSIOLOGICAL LUNG EXCLUSION
IS
AN EFFECTIVE ALTERNATIVE OPERATION
FOR
CONTROL OF MASSIVE OR RECURRENT
HEMOPTYSIS
WHERE
LUNG RESECTION IS DIFFICULT/HAZARDOUS
DUE TO
DENSE FIBROSIS, VASCULAR ADHESIONS &
CALCIFICATION

20. Other Surgical techniques
• Collapse Therapy - Thoracoplasty or
plombage
• Cavernostomy and packing
• Bronchial arteries ligation & ligation of
chest wall collateral vessels